Implementation Considerations Using HPV Self-Collection to Reach Women Under-Screened for Cervical Cancer in High-Income Settings

Abstract

The success of cytology (Pap screening) programs is undeniable and has drastically reduced cervical cancer rates in high-income settings where it has been implemented 1 . However, cytology for primary cervical cancer screening has a number of limitations including poor sensitivity, a taxing demand on human and operational infrastructure, high health system costs, and limited uptake rates, leading researchers and policy-makers to question whether further gains in public health are possible using this approach 2 . Persistent infection with high-risk genotypes of human papillomavirus (hpv) is well established as the necessary cause for development of cervical cancer 3 . Research has shown a 30% improvement in sensitivity in detecting high-grade lesions, cervical squamous intraepithelial neoplasia (cin) grade 2 or greater (cin2+), can be achieved with high-risk hpv dna testing compared with cytology 4 . A negative hpv test confers two-fold greater reassurance against the development of cervical cancer over three years compared with a negative cytology test 2,5 . The Netherlands has recently transitioned from cytology to hpv testing for primary cervical cancer screening in their National program. Many organized screening programs intend to implement primary hpv screening 6-9 , including Australia, which will begin implementation in December 2017.A consistent barrier to cytology-based cervical cancer screening is non-attendance, which can be addressed through hpv testing using self-collected samples. Primary cervical cancer screening with hpv dna testing allows for the opportunity of self-collected samples, which is not possible with cytology. In hpv self-collection the sample is obtained vaginally by the woman herself, using a device such as a swab or brush. The swab is subsequently tested for high-risk strains of hpv in a laboratory. With this approach to screening, programs can mail self-collection kits directly to women who are overdue for screening as an alternative to a clinic-based visit. Self-collected cervical samples receiving hpv testing show comparable cin2+ sensitivity compared with clinician-collected samples tested with cytology and with hpv 10-12 . Self-collection has proven to be highly acceptable among women 13 .Huma n papillomav ir us self-collection has t he potential to overcome many of the personal and systemlevel barriers to screening that exist for cytology or other clinic-based screening methods. Some women, particularly those who have experienced abuse 14 or are otherwise marginalized, may find self-sampling preferable because of such things as cultural/religious embarrassment or discomfort associated with a pelvic exam 13,[15][16][17] . Time, transportation, inconvenient clinic hours, or not having a regular practitioner are also relevant factors associated with under-screening that can be mitigated through hpv self-collection using mailed samples 13,16,17 . However, there are psychosocial barriers to hpv screening, including women's lack of awareness and fears around hpv and cervical cancer...

Knowledge, attitudes, beliefs, intentions and behaviours of Australian Indigenous women from NSW in response to the National Cervical Screening Program changes: a qualitative study

“…This was due to their concerns of not administering the procedure correctly, having to conduct the self-collection at a health care clinic and having to re-screen if HPV was detected. These findings differ from several other studies conducted in developed and developing countries in which self-collection was found to be effective in increasing participation in the cervical screening programs among under screened or never screened women either in the clinical setting or at home [36] , [37] , [38] , [39] , [40] , [41] , [42] . To explore the differences between our findings and other studies further research is required.…”

The experience of under-screened and never-screened participants using clinician-supported self-collection cervical screening within the Australian National Cervical Screening Program

“…Collection of a clinician-collected cervical screening test requires women or other people with a cervix (hereafter referred to as screening participants) to undergo a speculum examination performed by a practitioner to visualize the cervix and take a cervical sample. For people who are not screening at recommended intervals, there is a significant body of work describing the personal, practical and system-level barriers to clinician-collected cervical screening test, including embarrassment about undergoing a pelvic examination, 16 cultural barriers, 17 a history of trauma or sexual abuse 18 or a lack of time to attend primary care for screening. 19 Some of these barriers, particularly personal barriers which relate to the nature of the clinician-collected cervical screening test, can be addressed through self-collected cervical screening, where a screening participant can use a flocked swab to take their own HPV sample from their vagina.…”

Self-Collection for Cervical Screening Programs: From Research to Reality

“…[10]. Using self-collection, a woman can take the sampling device, insert it into her own vagina to collect a specimen, and then return it to a healthcare provider (either directly or through the mail) without the physical intervention of a healthcare practitioner [11]. This sample can then be processed using a nucleic acid test for the presence of HPV DNA or RNA.…”